Did you enjoy watching the 2016 Summer Olympics as much as my family and I did? We were glued to the TV for nights on end, delighting in Simone Biles and Aly Raisman on the mat, Katie Ledecky in the pool, and Jeff Henderson on the track, long jumping towards gold. We marveled at the giftedness and determination of the athletes, the cohesiveness of the teams, and the stories of family support and sacrifice. But there was one thing that my kids found perplexing– They scratched their heads and asked me, “Mom, what are those?” And I have an honest question for you: how many of you rolled your eyes a bit when you saw THOSE?
Cupping is just one in a long list of techniques included in Complementary and Alternative Medicine (CAM). As PTs, we field questions daily about the benefits of various treatments: “Does that cupping really work? Should I try acupuncture? My sister is studying Reiki—should I have her work on me? My chiropractor said my rib keeps popping out, so I need to see him weekly. Should I still do the PT exercises when it’s out?” As evidence-based practitioners, it can be very easy to become cynical about the explanations and interventions our patients are receiving from CAM providers, but before we roll our eyes or blurt out our gut reactions, let’s pause to think of this from a pain perspective.
First, a few definitions and statistics:
Complementary Therapies: Therapeutic interventions utilized in addition to traditional medical care, to supplement the mainstream remedy. A good example is someone who goes to yoga in addition to taking an anxiety medication to help get a handle how they respond to stress in their lives.
Alternative Medicine: Therapeutic interventions utilized instead of, or as a substitute for, traditional care. An example is someone who talks to their life coach about their anxiety and applies their advice without seeking help from a psychiatrist, psychologist, or licensed professional counselor.
Integrated Medicine: A growing field, which incorporates a combination of traditional and alternative techniques. Physicians practicing as in integrated medicine may prescribe both FDA approved medications as well as supplements and “Eastern” or other modalities to help patients with complex issues.
Complementary and Alternative Medicine (CAM): A broad category encompassing both supplemental and alternative modalities. These can be further divided into 5 categories:
|Mind-Body Therapies||Treatments that focus on how our mental and emotion status interacts with our body’s ability to function||Examples: Meditation, Art therapy, Music|
|Whole Medical Systems||Complete systems of medical theory and practice, many of which go back thousands of years and have roots in non-Western cultures||Examples: Chinese medicine, Aryuveda|
|Manipulative and Body-based Therapies||A practice intended to improve specific symptoms and overall health by relying on the physical manipulation of the body||Examples: Chiropractic, Osteopathy|
|Energy Medicine||Uses energy fields to promote healing. Biofield therapies affect energy fields that are said to encircle the human body.||Examples: Reiki, Qi Gong, Magnet Therapy,|
|Biologically Based Practices||Focus on herbs, nutrition, and vitamins, dietary supplements and herbal medicine.||Examples: Nutritional counseling from those other than registered dietitians|
Gildhayal et al. recently published a study entitled “Complementary and Alternative Medicine Use in the US Adult Low Back Pain Population”. The free article can be found here. Of 34,525 respondents surveyed, 9,665 participants reported having LBP within the last 3 months. In all, 41.2% of the LBP population used CAM in the past year, with higher use reported among those with limiting LBP. The most popular therapies used in the LBP population included herbal supplements, chiropractic manipulation, and massage. The majority of the LBP population used CAM specifically to treat back pain, and 58.1% of those who used CAM for their back pain perceived a great deal of benefit.
A slightly older survey by the CDC showed that 36% of 31,000+ respondents had used CAM the previous year (62% if prayer was considered part of CAM). Of note, 13% of CAM users used it because they felt conventional medicine was too expensive, and 28% used it because they believed conventional medical treatments would not help them with their health problem.
People are looking for answers for their pain. It behooves us as PTs to ask, “Where are they looking?” In April 2005, an ABC News/USA Today/Stanford University Medical Center poll was conducted by telephone, among a random national sample of 1,204 adults. The results have a three-point error margin:
Do you guys notice anyone who is missing from that chart? Where are WE??? Are we seriously sought out less that marijuana and booze? (Ummm…maybe don’t answer that). Were we even offered as a choice on the survey, and if not, why not? Have we not educated the general population that we are very good at treating pain? And, if asked, do you think 58% of patients with low back pain would answer that they received a “great deal of benefit” from physical therapy? Are we very good at it? How many patients have you seen who reported a low expectation for benefit, as they have tried PT in the past with little relief?
So, we are left in a conundrum. Many of our patients are seeking and regularly receiving CAM interventions. Many of them strongly believe it has been beneficial. They have great relationships with their providers and have no intention of giving that up. Yet when we hear the explanations that they have been told, our skin crawls. We also know that multiple explanations for why someone hurts are one of the “yellow flags” that tend to drive up the pain experience. Conflicting information can perpetuate tissue-based models and make it hard for us to “sell” neuroscience education. How do we contend with this?
One possible answer: Cut the ties. I have heard many PTs state that they tell patients they will not see them if they continue to receive services from their chiropractor/massage therapist/etc. This view has many advantages: we now have the patient all to ourselves and can assure that no misleading or scary information is being fed to the patient. We can help them understand the difference between pain issues and tissue issues and find a path to reasonable self-care. We can help break cycles of passive treatment and life-long dependence on others for relief. Of course this is the correct answer…right?
Unfortunately, there are some cons to taking a hard line on “cut the ties.” We all know how important therapeutic alliance is. Once a bond of trust has been forged between a practitioner and patient, anything that threatens that bond (i.e. you, the well-meaning PT, taking their chiropractor away from them…the chiropractor that has been the only one holding them together for the past seven years…), becomes a threat to the patient. And what happens when threat goes up? The alarm system activates and pain increases. Great—we’ve just shot ourselves in the foot, and we haven’t even gotten to know our patient yet. Another con is that sometimes we can be perceived as haughty or disrespectful towards another professional. Clearly, talking poorly about another practitioner does not reflect anything positive on us and undermines any therapeutic alliance that we are trying to build.
Another possible answer: Avoid the conversation. Just teach the patient “the truth” (at least our version of the truth…which just so happens to be STRONGLY rooted in evidence supporting the neuroscience of pain). Teach them pain science well enough and provide such excellent all-around care that they will come to their own conclusions about CAM and eventually stop seeing the others because we are Just. That. Good. But, as Patrick Wall said, “If we’re so good then why are our patients so bad?”
A third option: Go along with whatever narrative the patient believes. If they are convinced that rib keeps “popping out,” tell them you have a great exercise to help decrease the frequency of that. It makes sense to the patient, they are willing to try your advice, and they’ve already bought-in. Is that so wrong?
These are the questions I struggle with daily (and on occasion, keep me up at night!). To be honest, I have implemented all three of these options, and others, as the situation demands. I have made mistakes, sounded like a snob, alienated some folks, but also built bridges. I have worked hard to be honest with patients about what I think is going on with them, while trying to preserve a level of professional respect for the opinions of others. As a direct-pay practitioner, I see a large percentage of patients who are currently seeing CAM providers. They are happy to pay for highly skilled, individualized care, provided by a consistent therapist each visit…they have become accustom to that from the other clinicians in their world and now they are seeking the same in PT-Land. Heck, I see many CAM providers as patients! They have become some of my biggest referral sources, and generally, they buy in and are greatly appreciative when I share pain science with them.
I know we as PTs have essentially been trained from birth to hold certain other “professions” in a certain degree of suspicion, or dare I even say, contempt. But as we look at an epidemic facing our nation, where we lose more people to opioid overdoses every two months than we lost in 9/11, we have to ask: who is the real enemy here? Can we build bridges with our CAM providers for the greater good of our patients? Are they all full of cr–? Are they sly business people just out to make a buck off others’ pain and fear? Or are they (at least a good portion of them), well-intended, empathetic people who want to help others and are just seeing the patient through the filter of their own professional upbringing? We are all drinking Kool-Aid of one type or another, and for the sake of our patients, I hope we can figure out how to stay hydrated with our flavor of choice and still play nice in the sand box together.
Please share your thoughts…how do you walk the mainstream/CAM tight-rope? What common ground can we find, and what are some strategies to build bridges with those with whom we disagree?